Clinical factors related to admission and release decisions in psychiatric emergency services.

OBJECTIVE: The purpose of the study was to identify important clinical variables that influence admission and release decisions in psychiatric emergency services. METHODS: Physicians at four urban psychiatric emergency services rated 465 patients on ten clinical dimensions, including depression and psychosis. Information on five other variables-age, gender, ethnicity, diagnosis, and previous inpatient admission-were extracted from the patients' charts, as was information on case disposition. RESULTS: Logistic regression produced a model with five variables that significantly predicted admission or release. In order of importance, they were level of danger to self, severity of psychosis, ability to care for self, impulse control, and severity of depression. The model explained 51 percent of the variance in case disposition and correctly classified 84 percent of the cases. CONCLUSIONS: Guidelines addressing the variables that should be considered in making disposition decisions in psychiatric emergency services should be developed. The study found five variables that should be considered for inclusion.

Interrater agreement among psychiatrist in psychiatric emergency assessments.

OBJECTIVE: The authors' purpose in this study was to investigate the interrater agreement among psychiatrists in psychiatric emergency service settings. The interrater reliability of many of the key concepts in psychiatric emergency service settings has not been studied. METHOD: Videotapes of 30 psychiatric emergency service patient assessment interviews conducted by psychiatrists were shown to eight experienced psychiatric emergency service psychiatrists. The eight psychiatrists rated each videotape on dimensions such as severity of depression and psychosis and recommended a disposition for each patient. Interrater reliability was then explored. RESULTS: The level of agreement (intraclass correlation coefficient) among the reviewing psychiatrists was higher for psychosis and substance abuse but lower for psychopathology, impulse control problems, danger to self, and disposition. The reviewers' disposition recommendations did not match well with the assessing psychiatrist's actual disposition, but comparisons with actual practice should be considered only suggestive. CONCLUSIONS: Psychiatric emergency service assessments need improvement. This may be accomplished by exploring the underlying structure of psychiatric emergency service concepts, the creation and validation of structured assessment tools, and the creation of practice guidelines.

An analysis of police referrals to 10 psychiatric emergency rooms.

Data were collected on all psychiatric referrals to 10 emergency rooms in New York State during a 72-hour period in early December 1988. Overall, 30 percent of the 362 cases were brought by the police while the 10 emergency room percentages referrals varied from 10 to 53 percent. As compared with nonpolice referrals, police cases were as likely to be rated by clinicians as currently having psychotic symptoms, having a severe mental disorder, currently using substances, having a major mental illness diagnosis, and/or being referred to the emergency room for threatening to do harm or actually harming self. Police cases were more likely than nonpolice referrals to be male, to be referred to the emergency room due to impaired judgment or dangerous behavior to others, to be admitted to a psychiatric inpatient setting, and/or to have a longer length of stay in the emergency room. In addition, at municipal hospitals only, police referrals were more likely to be assaultive in the emergency room and/or not have payment resources. A logistic regression differentiated police cases from nonpolice cases on dangerous behavior to others and impaired judgment as reasons for referral, payment resources in municipal hospitals, and gender but not on any of the mental disorder variables. Policy implications for training and access to pretransport information and consultation are discussed.

Factors predicting referral to inpatient or outpatient treatment from psychiatric emergency services.

Dispositional decisions in ten psychiatric emergency rooms in New York State were examined using logistic regression. Variables influencing recommendations for inpatient or outpatient psychiatric treatment were fairly consistent across the hospitals. All terms used in the regression model were interactions formed from five variables: dangerous behavior as a reason for referral, severity of the mental disorder, the hospital where the patient presented, current signs of psychosis, and a diagnosis of major mental illness. A sixth variable, assaultive behavior in the emergency room, also influenced disposition decisions but could not be considered in the model because all patients with that characteristic were referred for inpatient treatment. A model of disposition decisions based on interactions of variables may be especially powerful because it captures the dynamic combination of factors clinicians encounter.

The relationship between patient-staff ratio and reported patient incidents.

The relationship between patient-staff ratio and the prevalence of patient incidents, such as assaults, fighting, suicides, falls, and abuse of patients by staff, was examined at an urban inpatient psychiatric center. Stepwise logistic regression was used to analyze 5,375 shifts in 14 high-incident wards representing five types of inpatient services; sample periods from three different years were examined. At least one incident occurred during 411 shifts (7.6 percent). More incidents occurred on the day shift and on two specific wards, confirming previous findings of a relationship between incidents and time of day as well as patient characteristics and milieu. However, no relationship between patient-staff ratio and the occurrence of incidents was found. This finding suggests that small increases in the number of ward staff may not reduce the number of patient incidents.

Forensic psychiatric inpatients served in the United States: regional and system differences.

This research note presents data about regional and system variations in psychiatric inpatient services for forensic patients provided in state operated psychiatric inpatient programs in the United States in 1986. Patient census by legal status and service provision information were collected from state forensic directors. In 1986, about 5,400 patients found not guilty by reason of insanity (NGRI) and 3,200 patients found incompetent to stand trial (IST) were being served in state operated inpatient units. About 70 percent of both groups were being served in designated forensic beds. There were wide differences among the states in the volume and rates for NGRI, IST, forensic exams, and dangerous civil patients (DCP). The regional analyses revealed large variability among states within each region.

Staffing of forensic inpatient services in the United States.

Data on patient census, bed capacity, and staffing levels in state-operated forensic psychiatric inpatient programs in 1986 were collected from forensic mental health directors of the 50 states and the District of Columbia. Of the 75 programs identified, 54 were based in units within larger psychiatric hospitals and 21 in freestanding hospitals. For all programs, direct-care staff-patient ratios ranged from .35 to 4, with a mean of 1.3. The ratio of filled beds to bed capacity ranged from .5 to 1.54, with a mean of .95. Nearly a fourth of the programs were over capacity. A negative relationship between filled-bed ratios and direct-care staff-patient ratios was found.

Use of seclusion and restraint in public psychiatric hospitals: patient characteristics and facility effects.

Use of seclusion and restraint in 23 adult public psychiatric hospitals in New York State was examined by comparing demographic and diagnostic characteristics of 657 patients who were secluded or restrained during a four-week period with characteristics of 22,939 patients who were not. Logit analysis was used to calculate the probability of seclusion and restraint of individual patients with various combinations of characteristics. Characteristics associated with high probabilities included age less than 26 years, length of stay from 30 to 365 days, involuntary legal status, female gender, a diagnosis of mental retardation, and residence in a hospital with a high rate of seclusion and restraint. The rate of seclusion and restrain in the 23 hospitals ranged from .4 to 9.4 percent of patients. Both patient characteristics and the hospital of residence were needed to explain the case-by-case probability of a patient's being secluded or restrained.

Incident reporting: evaluation of New York's pilot incident logging system.

A revised incident reporting system that combined an abbreviated logging procedure for documenting minor incidents and a more comprehensive and detailed procedure for documenting major incidents was pilot tested in three New York State adult psychiatric centers. The pilot test had two major goals: to reduce the volume of work associated with current reporting procedures, and to facilitate even more thorough investigation of incidents warranting prompt and comprehensive review. Evaluation of pilot study data showed that a logging procedure is viable for the management of minor incidents.

Constructing an efficient inpatient incident reporting system.

The NYS Office of Mental Health invests significant staff resources in documenting, investigating, and reviewing minor incidents. This process generates an enormous amount of paperwork. A study by the NYS Commission on Quality of Care revealed that this investment, in fact, compromised the intended positive outcomes. A major flaw they cited was the requirement for identical reporting procedures for both major and minor incidents. A logging system for reporting minor incidents was developed and pilot tested in three OMH psychiatric hospitals. The study revealed that utilization of a log system for the reporting of minor incidents greatly reduced paperwork and staff time, and that these reductions were accomplished without detriment to the quality of care. In fact, the quality of patient care may have improved. More incidents were being reported, a stable record was available on wards for clinical review, staff were enthusiastic about the log system, perhaps improving their morale, and direct care staff had more time available to spend with patients. This type of logging system for the reporting of minor incidents would appear applicable to practically all inpatient psychiatric settings, and, if employed as intended, could be expected to contribute to an improved quality of patient care.

Trends in New York State secure care patients: 1980-1982.

Demographic and clinical characteristics of patients in special security units in New York State psychiatric centers are examined over time. The percentage of recently dangerous patients increased dramatically over the first three years of "official" operation. In addition there were increases in the percentages of patients with physical problems, alcohol/drug problems, and mental retardation diagnoses.

Assessing the operation of secure care programs in New York State facilities.

In 1980 New York State's Office of Mental Health began operation of a program designed to provide a secure treatment unit at each of the 23 state psychiatric centers. As part of a research project to assess the operation of the units, demographic and hospitalization data were gathered on all clients residing on, and admitted to, the 14 operational units over a five-month period in 1982. Clinical data and information on program operation were also obtained. Results indicated that the units were generally functioning as planned, primarily serving young male civil patients referred for assaultive behavior. The patients were significantly more likely to have been involved in incidents of dangerous behavior and to have been in restraint or seclusion than were patients on comparison wards. The study also found that the secure units had been effective in reducing the rate of such incidents for the patients served. However, some data suggested the presence of an inappropriate population on certain units.